Thursday, April 05, 2012

What do you do when the doctor says - " I do not know"

“ I do not know “ is often the only truthful answer for many questions which infertile patients ask us . Why was my ovarian response so poor ? Why is my sperm motility so low ? Why didn't we get more embryos ? Why didn't the embryos implant ? Why didn't the hCG levels rise ?

The truth is that we often don't know the answers to these questions , because we just don't have the technology to answer them. While we do have a rough idea of what the likely probable outcomes are for a group of patients doing IVF, we just don’t have the ability to quantify this for the individual patient , and patients need to understand this.

However, if you give the patient an honest – “ I do not know “, patients get extremely upset and agitated. They wonder ( privately !) about how competent and well informed you are . Are you really a good doctor? After all , isn't a doctor meant to be an expert who knows everything ? What’s the point of a doctor if he doesn’t have answers to these basic questions ? Is it time to find another doctor , then - perhaps someone who is better informed and who has all the answers?

Most doctors will not take the time and trouble to explain to patients why we are not able to answer some of these simple questions accurately . Most them will resort to providing what I call pseudo-answers. They will order a battery of tests , which will then provide a lot of irrelevant results. Some of these ( simply by the laws of probability ) are definitely going to be abnormal ! They then gleefully point to these abnormal results, and claim to have found out what went wrong ! In reality , these so-called abnormalities are just red herrings , which have no real bearing on that individual patient's problem.

However, once this so-called problem has been identified , the patient is happy , because she is impressed as to how clever this doctor is - he's been able to identify what earlier doctors couldn't, because he was smart enough to order this new ( and often very expensive !) test. This strategy is also useful for doctors , because they don't have to spend so much time and energy explaining the basics to patients; and can then just go ahead with a cookbook protocol for treating the “ abnormality”.

Unfortunately, this kind of mindless testing gives rise to a lot of overtesting and overtreatment , which actually doesn't help patients at all.

An expert who has the confidence in his abilities to tell you I do not know is quite likely to be a good doctor , because he knows what the limits of medical science are, and is willing to share them with you.

There is no reason to get upset if we do not know the precise answer in your particular case. This ignorance is true for lots of things in life, and doctors are used to handling this uncertainty because it is an integral part of medical science. It's important to do your homework for yourself, so you can educate yourself , and have a better understanding of exactly what the limits of medical knowledge of.

If a doctor tells you that he does not know , this does not mean that he is ignorant or incompetent. It just reinforces the fact that medical science has its limitations ; and we still need to learn a lot more about basic reproductive biology , before we can answer some of our patient’s basic questions !

3 comments:

I do not think patients get impressed by a doctor who knows everything or who pretends that he knows everything. When we ask something about our medical condition we do not expect a precise scientific answer, we just need a comforting word. ‘I do not know’ can be said in many different ways. For example, when I asked why I am responding so poorly to stimulation drugs, I got two different responses from two different REs. The first one said ‘how do I know, it’s your ovaries!’ (Does it mean I am supposed to know the answer just because they are my ovaries? :O !!!). The next one answered ‘I wish I knew the answer. Human body reacts very differently every time since, it’s a very complex entity. People get pregnant even with such poor responses. Remember, all that we need is a single good egg and hopefully we get it this time’. Both of them said the same thing but in a very different way :). There is also a third variety ‘the know-it-all’ type who is very insensitive to human emotions. They try to showcase their extreme knowledge first. Their reaction will be like ‘might be you are running out of eggs!’. I do not have to say which RE type will be appreciated and adored by the patients!